Is the patient covered by commercial insurance coverage?*

Does the patient reside in the United States or Puerto Rico?*

Is the patient who will use this coupon eligible for reimbursement of prescriptions (in whole or in part) under any federal, state or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan or any other federal or state healthcare programs?*

I authorize my child's healthcare providers and staff, pharmacies, and health insurers to use and to disclose to Sobi, Inc., and its affiliates, business partners, vendors, and other agents (collectively, “Sobi”) health information about my child, including information related to my child's medical condition and treatment, health insurance and coverage claims, and prescription (including fill/refill information) for SYNAGIS (“Information”) to (1) enroll my child in and provide services under the SYNAGIS CONNECT™ patient support program (the “Program”); (2) obtain information on my child's insurance coverage; (3) coordinate prescription fulfillment as indicated by my child's physician; (4) provide me with adherence reminders and support; and (5) contact me to conduct market research and to arrange for my receipt of educational, promotional, and/or marketing materials about Sobi support programs or Sobi products. Once my child's Information has been disclosed to Sobi, I understand that federal privacy laws may no longer protect it from further disclosure. However, I also understand that Sobi will protect my child's Information by using and disclosing it only for the purposes allowed by me in this Authorization or as otherwise required by law.
I understand and agree that the pharmacy that dispenses SYNAGIS may receive payment from Sobi in exchange for disclosing my child's Information to Sobi and providing Program services.
I understand that I do not have to sign this Authorization. A decision by me not to sign this Authorization will not affect my child's ability to obtain medical treatment from healthcare providers, eligibility for health insurance benefits, or access to Sobi medications. However, if I do not sign this Authorization, I understand my child will not be able to participate in the Program.
I understand that this Authorization expires ten years from the date signed below, or as otherwise required by state or local law, unless and until I cancel (take back) this Authorization before then. I may change my mind and cancel this Authorization at any time by calling 1-833-SYNAGIS (1-833-796-2447) or by notifying Sobi in writing at SYNAGIS CONNECT, PO Box 29076, Phoenix, AZ 85038-9076. Cancellation of this Authorization will end further uses and disclosures of my child's Information and my child's participation in the Program but will not affect any uses or disclosure of my child's Information made by my child's health care providers and staff, pharmacies, and health insurers based on this Authorization before receipt of the cancellation. I understand I may request a signed copy of this Authorization.*

By clicking the submit button, I am agreeing that all information contained in this enrollment is complete and accurate*

By clicking the submit button, I am agreeing that I have read, understood and will comply with the terms and conditions of the program and that patient currently meets all eligibility criteria.

Limitations apply. Valid only for those with private insurance. The program includes the copay card, payment card (if applicable) with a combined annual limit of $6,000. Patient is responsible for any costs once the dollar limit is reached during the program term (July-June) calendar year. Program is not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD or any other federal or state health care program, (ii) where patient is not using insurance coverage at all, or (iii) where the patients' insurance plan reimbursees the entire cost of the drug. The value of the program is exclusively for the benefit of patients and is not intended to be credited toward patient -pocket obligations and maximums, including applicable co-payments, co-insurance and deductibles. Program is not valid where prohibited by law. Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the program. Valid only in the United States and Puerto Rico. This program is not health insurance. Program may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required. Sobi, Inc. reserves the right to rescind, revoke, or amend the program and discontinue support at any time without notice.